Atypical presentation of a mediastinal mass in an adolescent: Critical care considerations

Objective: To describe the clinical course and treatment of a large mediastinal mass with unusual presentation and critical lower airway compression in an adolescent. Design: Case report. Setting: Pediatric intensive care unit in a tertiary care, academic children's hospital. Patients: A previously well 15-yr-old boy presented to an outside physician with a 2-mo history of widening of his fingernail beds, progressing within a month of admission to fatigue, weight loss, progressive cough, and dyspnea on exertion. One week before admission, he developed facial swelling, headache, and large neck, chest, and abdomen veins. At the time of admission, he was hypoxic and had a large mediastinal mass with severe lower airway compromise, right-sided atelectasis and pleural effusion, as well as significant right atrial compression on chest computed tomography. Intervention: The patient was placed in the pediatric intensive care unit and underwent emergent tube thoracostomy and drainage of the pleural effusion in the upright position, using a local anesthetic. Results: The patient developed mild reexpansion pulmonary edema with worsening hypoxia, which was managed using bilevel positive airway pressure. Pleural fluid was nondiagnostic, as was bone marrow aspirate and biopsy done in similar fashion on day 2. The patient then underwent a fine-needle biopsy in the operating room, also nonintubated and upright, which diagnosed non-Hodgkin's lymphoma, nodular sclerosing type. Treatment for tumor lysis syndrome and chemotherapy were initiated, and he progressively improved. Conclusions: Mediastinal mass with true critical airway and vascular compromise is often discussed but infrequently seen in the pediatric intensive care unit. This case shows not only unusual associated signs of lymphoma (clubbing and caput medusae) but more importantly the rapid identification and thoughtful management of the patient's respiratory compromise. This case serves to remind the pediatric intensivist of alternative ways to provide analgesia safely in such patients for lifesaving as well as diagnostic invasive procedures. (Pediatr Crit Care Med 2010; 11: e44-e47)